Provider Demographics
NPI:1538873948
Name:BRAVO, GRENELYN FABONAN
Entity type:Individual
Prefix:
First Name:GRENELYN
Middle Name:FABONAN
Last Name:BRAVO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6415 CAMELLIA GARDEN DR APT 305
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-6305
Mailing Address - Country:US
Mailing Address - Phone:321-848-2947
Mailing Address - Fax:
Practice Address - Street 1:6415 CAMELLIA GARDEN DR APT 305
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-6305
Practice Address - Country:US
Practice Address - Phone:321-848-2947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT35650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist